Legal Name:
DBA, if applicable:
Address:
City: State:
ZIP:
Phone:
Fax: EIN:
Type of Company (Enter: Corporation, or Partnership,
or Proprietorship, or LLC):
State of Incorporation:
Type of business:
Number of Employees:
With whom have Applicant ever factored its accounts
receivable, if applicable:
Annual Sales Volume:
Maximal Monthly Sales Volume:
Minimal Monthly Sales Volume:
Number of Active Customers:
Number of Invoices per Month:
Amount of bad debt written off by Applicant last
year, if any:
Provide information on any pending Lawsuits,
or back Taxes, or Judgments or Liens filed against Applicant or its Principal(s):
Balance owed on all outstanding loans:
List all Lenders/Financial Institutions:
Provide information on the terms of these loans,
if accounts receivable are pledged as collateral:
Provide information if any security interest
has been granted that covers accounts receivable or inventory:
Amount you wish to factor monthly:
List Applicant's 5 Largest Customers to factor (Customers
will not initially be contacted)
Company Name
City/State
Phone Number
Monthly Sales ($)
Average Invoice ($) /Aging
Officer Name/Title
Home Address
Social Security #
Date of Birth
Ownership (%)
Professional References
Attorney:
Phone:
Accountant:
Phone:
Statement
The foregoing information is true and correct to
the best of my knowledge and is given to Dollar Express Corporation to
consider entering into a factoring agreement. I do hereby authorize Dollar
Express Corporation or its agents or underwriters to verify and investigate
any and all of the foregoing statements, including but not limited to my/our
credit worthiness and financial responsibility, in any legal way they may
choose. I / we grant Dollar Express Corporation and its underwriter the
right to procure any and all credit reports pertaining to any party listed
in this application, including, but not limited to, all principals of the
applicant company.
The above statement is agreed and consented to
upon on-line submission of this form by:
Name:
Title:
Date:
